De Wolf, Daniël

Delree, M

Deneyer, M

Keuppens, F

Sacre-Smits, L

Temmerman, M

Verboven, M

Ghent University Academic Bibliography

Eur J Pediatr (1989) 149 :62-64 European Journal of Pediatrics 9 Springer-Verlag 1989 Antenatal diagnosis of urological disorders by ultrasound: a critical review D. DeWol f  I , F. Keuppens 2, M. Temmerman 3, M. Verboven 1, M. Deneyer I , M. Delree 4, and L. Sacre-Smits I 1Department of Paediatrics, ZDepartment of Urology, 3Department of Gynaecology, and 4Department of Radiology, Aeademisch Ziekenhuis, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium Abstract. The suspected iagnosis of urological disorders made on the basis of antenatal u trasonography was compared with the final outcome in 23 cases. In 18 cases the initial diag- nosis could be confirmed, whereas 5 showed no postnatal urological anomalies. Further efforts should be undertaken toimprove prenatal diagnosis in order to facilitate treatment as early as possible. Key words: Fetal - Urology - Ultrasound Introduction The accuracy of antenatal ultrasonography of the fetal uro- genital tract is compared with the results of postnatal observa- tions. Ultrasonography used for screening all pregnant women in order to determine gestational ge has proved to be of benefit in detecting fetal anomalies. Offprint requests to: D. De Wolf Methods The following criteria were used in patient selection: (1) all women underwent antenatal u trasonography in the obstetrics and gynaecology unit of the Akademisch Ziekenhuis, Vrije Universiteit, Brussel; (2) antenatal ultrasonography was per- formed with a real time Toshiba SAL 77A (Antwerp, Bel- gium); (3) all women delivered in hospital; (4) the neonates were observed uring the first 7 days of life; (5) a least one postnatal ultrasound control and cystourethrography were performed; (6) the children were followed up for 3 years. Results During 1985, a total of 900 women were selected according to the above-described criteria. Urogenital disorders were ob- served in 23 fetuses between 28 and 34 weeks of gestation. The antenatal findings can be divided into five categories (Table 1). Table 1. Postnatal evaluation of antenatal diagnosis Antenatal diagnosis n Postnatal diagnosis n Group i Isolated cystic image 9 Multicystic kidney 3 Group 2 Hydronephrosis uni- or bilateral Group 3 Hydronephrosis with oligohydramnios Group 4 Megacystis Group 5 Absent kidney Multicystic kidney on pelviureteric junction obstruction 1 Mega-ureter 1 Duplicated ureter 1 Ovarian cyst 1 Normal 2 10 Pelviureteric junction obstruction 3 Mega-ureter 1 Duplicated ureter with ureterocoele 1 Ureter stenosis 1 Anatomical variant (partial extrarenal pelvis) 2 Normal 2 2 Bilateral vesico-ureteral junction obstruction 1 Posterior urethral valve 1 1 Normal 1 1 Ectopic kidney and vesicoureteral eflux 1 23 23 other life-threatening ~efects counsel 4 no intervdon termination I poor function Fig. 1. Algorithm for prenatal bilateral hydronephrosis ultrasound no associated defects otigohydra4mnios adequ~e amniotic fluid prognostic evaluation ultrasound + counsel weekly take fetal urine I ~ decreased normal good function lungs mature lungs immature delive early/ decompression delivery at term correct ex utero in utero correct ex utero 63 The 1st group consisted of 9 fetuses with presumed cystic malformation. In 2 of these, the findings could not be con- firmed on postnatal ultrasonography. In a 2nd group of 10 cases, antenatal ultrasonography demonstrated hydronephro- sis. Two of these 10 cases were found to be normal after birth and 2 others displayed normal anatomical variations, namely partial extrarenal pelvis. In a 3rd group, 2 cases of hydronephrosis with oligo- hydramnios and suspected bladder dilation were observed. In the 4th group, 1 case of bladder dilatation was observed; this was confirmed on several occasions, but not after birth. Group 5 consisted of i case with an absent kidney. Five out of 23 suspected anomalies could not be confirmed postnatally; this represents 22% of the total patient popula- tion. On postnatal follow-up, 2 supplementary cases presented as partial extrarenal pelvis, a normal anatomical variation. All malformations were confirmed by radiography, isotopic or anatomopathological nvestigations. One fetus presented at 30 weeks of gestation with a renal cyst compressing the other abdominal organs. It was trans- cutaneously aspired. Only a small dysplastic kidney with a glomerular filtration rate of less than 10 ml/min remained after birth. Labour was induced at 38 weeks in 2 cases due to compli- cations, namely obstruction of the pelviureteric junction. The first case was observed as a worsening hydronephrosis which proved to be bilateral after birth. The other presented with ex- treme intra-abdominal compression due to a unilateral multi- cystic kidney. However, drainage of the major cysts did not relieve intra-abdominal compression. An explorative lapara- tomy was performed in the neonatal period because of further complications (pneumothorax, intestinal obstruction) and revealed a multicystic dysplastic kidney, which was removed. The anatomopathological findings confirmed the existence of a unilateral pelviureteric obstruction. Post-operative r covery was excellent. Discussion These studies confirm that antenatal ultrasonography pro- vides important information for the rapid diagnosis of urogen- ital malformations [2, 13, 16]. Its reliability is not absolute be- cause of difficulties in differentiating between certain dis- orders, such as multicystic kidney versus pelviureteric junction obstruction and hypoplastic kidneys versus bilateral renal agenesis [2]. Moreover, the exact number of false-negative ex- aminations i unknown. Therefore, theoretically, the urogeni- tal system of all newborns hould be screened. Striking are the five cases presumed to be transient dilata- tions of the urinary tract. This has also been found by other authors [2, 9, 10], but the mechanism of this phenomenon isstill controversial. The hydronephrosis could be related to the maximal sodium concentration and the increased urinary out- put of the 27-week-old fetus [2, 5, 7]. Moreover, dilatation could also be caused by immaturity and incomplete mptying of the bladder or even transient vesicoureteral reflux [2, 3, 10]. This implies that even with normal postnatal ultrasonography, a (voiding) cystourethrography is necessary to complete the diagnostic evaluation. Since antenatal ultrasonography provides a reliable diag- nostic tool, an accurate antenatal and postnatal approach to the information obtained by this technique is essential. We consider that at least a control ultrasonogram ust be per- formed during the early neonatal period. If this is normal, then a transient process can be considered, and cystourethrog- raphy is indicated to exclude vesicoureteral reflux [13, 16]. A negative xamination should be followed by ultrasonog- raphy at 3 months of age. Conversely, if the antenatal patho- logical findings are confirmed by the early postnatal examina- tion, then cystourethrography remains the first choice exami- nation to exclude vesicoureteral reflux, posterior urethral val- ves or urethral stenosis. If cystourethrography is unable to establish an aetiology for hydronephrosis or multicystic kidney, then urography can exclude pelviureteric junction obstruction or distal uretero- vesical stenosis [13, 16, 17]. In cases of doubt, a percutaneous puncture with contrast dye injection can confirm pelviureteric junction obstruction. Ifnecessary this can be followed by the positioning of a per- cutaneous nephrostomy tube to relieve obstruction and enable evaluation of renal function [16]. In those cases where im- mediate drainage seems unnecessary (i.e. moderate hydro- nephrosis, multicystic kidneys with satisfactory renal func- tion), renal function must be assessed by urography with 

Antenatal diagnosis of urological disorders by ultrasound : a critical review

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